I. Problem/Challenge.

Improving the quality of care transitions is a priority among hospitalists and healthcare organizations. One of the most important, and often most complex, patient transitions is the hospital discharge. With hospital length of stay having decreased over time, patients are now being discharged before they are fully recovered from their acute illness, i.e. "quicker and sicker". As a result, patients often have significant continued care needs post-discharge. Additionally, increasing attention is being paid to hospital readmission rates, leading to increased recognition of the need to optimize post-acute care services. Careful discharge planning during the hospitalization is essential to improving resource utilization and patient safety during the discharge transition.

A wide range of post-acute care services and settings are available for patients after discharge, including skilled nursing facilities, long-term acute care facilities, inpatient rehabilitation, outpatient rehabilitation, home health services, hospice care, and self-care. The focus of this chapter is home health planning.

II. Identify the Goal Behavior

In order to execute the transition from hospital to home in a safe and efficient manner, early planning and interdisciplinary coordination are required. As such, hospitalists should understand the types of home health services that are available, be able to identify which patients are appropriate for home care and know who to contact to arrange these services

Types of home care services

Home health agencies provide multidisciplinary services, including but not limited to:

◦ These services typically require a motivated patient/caregiver, as home health nurses will provide teaching, but patients/caregivers may be expected to perform some tasks on their own, especially if care is required more than twice daily.

Physical therapy (PT)

◦ Restoration of mobility and function, assessment of home safety and equipment needs, patient and caregiver education, home exercise programs.

Occupational therapy (OT)

◦ Training with self-care tasks and other activities of daily living (ADLs), administration of splints and adaptive equipment, patient and caregiver education.

Appropriate patients for home care

Patients should be considered for home care if they are expected to discharge home and have specific and intermittent post-discharge needs, such as those listed above. Certain patient populations, such as the elderly, patients with multiple comorbidities or recurrent hospitalizations, those with functional impairment or limited social support, or history of non-compliance or lower health literacy, are at high risk for readmission and may therefore benefit most from home care services. For many patients, home care can be a cost-effective service and allow both patients and their caregivers to play a more active role in their health care.

In order to be eligible for the Medicare home health benefit, patients must be homebound. Homebound means that leaving home takes a considerable and taxing effort, or requires the assistance of another person, an assistive device or special transportation. Patients who are homebound may leave home for short periods for medical appointments or religious services.In addition, patients must be under the care of a physician and that physician must review and certify the plan of care. Lastly, services must be medically necessary, and the need must be intermittent rather than continuous.

The discharge planning team

The Joint Commission requires that hospitals have discharge planning processes applicable to all patients. Expectations are that each hospital begins the discharge process early during the patient's episode of care and evaluates each patient for the need for psychosocial or physical care after discharge. Hospitals should assist in arranging any services required by the patient after discharge, and are responsible for communicating the plan of care to the patient and/or caregiver and subsequent providers. The standards specify that hospitals list home health agencies that contract with the patient's payer and serve the patient's geographic area.

Studies have shown that structured discharge planning programs are associated with shorter hospital length of stay, lower rates of hospital readmissions and increased patient satisfaction. Some characteristics of effective discharge planning programs include standardization of procedures, identification of social needs, use of tools to facilitate communication with outpatient providers, provision of disease-specific education with active learning techniques, scheduling of follow-up appointments, and attentiveness to medication reconciliation. Another key feature of successful discharge planning programs is the use of an interdisciplinary team. Recommendations from bedside nurses, social workers, case managers, pharmacists, and therapists can be invaluable to hospitalists when coordinating a patient's discharge to home. Having clearly defined roles and responsibilities for each team member (e.g., pharmacists assist with medication reconciliation, case managers help coordinate home health agencies and follow-up appointments, nurses perform patient and caregiver education), as well as a forum to discuss these needs for each patient, are critical to ensuring a safe discharge transition.

III. Describe a step-by-step approach/method to this problem.

Step 1: take a comprehensive social history at hospital admission

When patients transition from the acute care setting to home, the burden of care shifts from the inpatient providers to the patient, family and outpatient providers. With this in mind, the admission encounter and in particular the social history should be viewed as an opportunity to collect and update information regarding the patient's living situation, social support and baseline functional status. This information will aid in the identification of patients who may need more focused assessments and interventions by the discharge planning team. Specific questions of interest include:

Living situation - where does the patient reside?

◦ From what setting is the patient being admitted (e.g., home, assisted living facility, skilled nursing facility, long-term care facility)?

◦ If the patient lives at "home," obtain more details:

▪ Does the patient live in a house, an apartment, a senior living center, or other place of residence?

▪ Does the patient intend to return to that residence at discharge?

▪ Does the patient live alone? If not, obtain details regarding who lives with the patient.

Social support - who does the patient rely on for help?

◦ If the patient lives alone, is there a family member, friend, neighbor, or other caregiver who provides support on a regular basis? If so, who is that individual and what is his or her relationship to the patient?

◦ If the patient lives with other individual(s), is the spouse, family and/or roommate physically able to provide sufficient support?

Baseline functional status - in his or her usual state of health, how independent is the patient?

◦ Is the patient independent with instrumental activities of daily living (IADLs, e.g., using the telephone and transportation, managing medications and finances, shopping, preparing meals, housekeeping)?

◦ If not, who helps with these activities and how much assistance does the patient require?

◦ Does the patient have any home services currently?

Cognitive status

Health literacy level

Step 2: begin the planning process

Successful discharge planning begins at admission. With a good social history, the hospitalist should have a sense of the patient's outpatient support system. At, or shortly after, admission, the hospitalist can begin to determine what medical or skilled needs the patient will have once his or her acute issues start to improve. Communicating these anticipated needs to the discharge planning team as early as possible is critical. Delays in this step can lead to prolonged hospital length of stay or incomplete care coordination at discharge.

Consult other specialists based on patients' anticipated needs in the post-discharge period.

◦ Should a patient require an extended course of intravenous antibiotics, you may consider consulting the infectious disease service to facilitate proper antibiotic choice, duration and outpatient monitoring. A peripherally inserted central catheter (PICC) will also need to be placed, when clinically appropriate.

◦ Patients with recurrent admissions for congestive heart failure or chronically uncontrolled diabetes may benefit from nutrition or pharmacy counseling during the inpatient stay or the corresponding subspecialty consult to clarify the discharge medication regimen and outpatient follow-up plans.

◦ If you anticipate that a patient may need home oxygen, ensure that the appropriate documentation is available.

Communicate frequently with your case manager and/or social worker.

◦ These team members are experts in discharge planning and will assist with referrals to home care, communication with patients and caregivers, provision of community resources, and ordering of durable medical equipment.

Ensure adequate outpatient follow-up.

◦ Identify the patient's primary care physician (PCP); when possible, schedule the follow-up appointment prior to discharge, so that the patient leaves the hospital knowing when the appointment is and understanding how to get there.

◦ Clarify which outpatient providers will be following any necessary labs (e.g., antibiotic monitoring, anticoagulation monitoring).

◦ Particularly with home nursing services, coordinate the timing of the first home visit to correspond with the patient's specific skilled needs. For IV antibiotics, home health services can often be arranged to begin on the day of or after discharge.

Step 3: execute the discharge transition

Proper discharge planning that begins at hospital admission should decrease workload and improve efficiency on the day of discharge. Once the decision for discharge has been made and orders for home health have been completed, there are a few additional tasks that must be addressed at discharge to minimize the risk of errors.

As is the case with all patients who are discharged, medications should be carefully reconciled, instructions for diet, activity and follow-up should be reviewed, and patients/caregivers should be given the opportunity to ask questions. All patient instructions should be provided in language appropriate for the patient's literacy level. Patients should be educated about specific symptoms to watch for, and what to do should concerning symptoms or questions arise. A discharge summary should be forwarded to the patient's PCP, and closed-loop communication should be conducted with any outpatient providers who will need to provide specific monitoring (e.g., following weekly labs for a patient on long-term antibiotics) or who will be expected to follow-up any specific tests (e.g., blood cultures that have not yet been finalized at the time of discharge).

IV. Common pitfalls.

Discharge planning is a complex process and there are several common pitfalls that with proper education and support, hospitalists can avoid:

Lack of knowledge about available services

◦ Talk with your case manager and social worker to learn about the spectrum of home support services that can be provided.

Not investing the time up-front to understand the patient's social circumstances and support system

Not indicating who the PCP is for the home health agency

◦ Do indicate the name of the outpatient provider to whom additional communication should be directed; otherwise, the hospitalist may continue to get contacted about home health orders.

Not completing the Face to Face Encounter Form for Medicare patients

◦ Some agencies may not initiate home services until this documentation is complete.

◦ Wean oxygen, discontinue foley as soon as appropriate to ensure that patients will not require these supplies at discharge.

Delays in ordering necessary tests or procedures

◦ Do not wait until the day of discharge to order the PICC placement or swallowing study, finalize medication orders, or consult infectious disease or the diabetic educator.

V. National Standards, Core Indicators and Quality Measures.

Several national organizations and experts have issued recommendations regarding best practices for discharge.

As above, the Centers for Medicare & Medicaid Services (CMS) have specific requirements regarding eligibility for home health care. Patients must meet criteria for being homebound and have specific skilled needs identified by their provider. A face to face encounter form must be completed at the time of referral for home services, and the plan of care must be signed within 30 days.